High Blood Pressure and Cholesterol

In his article, “Do You Have a Good Blood Pressure,” Paul J. Rosch, M.D. exposes the fallacies behind the “one-size fits all” approach to regulating blood pressure. He sites the example of seniors feeling very weak if their blood pressure is below 120/80 to explain that different factors (ex. age, sex, etc.) need to be considered when determining the healthy blood pressure range for a particular individual. He explains that in order to successfully treat a disease it is necessary to eliminate its cause rather than its manifestations. Treating a persistently elevated blood pressure, he explains, does the latter, which is why responses to blood pressure medication are much less predictable than medications used to treat diseases. Hypertension is not a diagnosis of a disease, but rather a description that can have many different possible causes. Moreover, an elevated blood pressure may be a purposeful physiological response, such as to maintain adequate blood flow to kidneys and other vital organs.

The fact that many physicians attempt to regulate “high blood pressure,” he explains, relates to a misunderstanding of what risk factors really represent. Most so called “risk factors” of heart disease, he explains, are really “risk markers.” They simply have a statistical association with an increased incidence of coronary events rather than a causal relationship. Thinking that you are curing heart disease by lowering blood pressure is as unsound as thinking you are curing heart disease by reversing premature baldness or lowering selenium toenail levels (both of which are risk factors for heart attacks).

Rosch also points to the difficulty of taking an accurate reading of someone’s blood pressure. More than one in four patients with elevated blood pressures in the doctor’s office were found to have normal values on ambulatory monitoring and were all taken off their drugs without any adverse reactions. Doctors used to respect this discrepancy, but now time does not allow for them to let their patients relax before taking another reading. Another overlooked fact is that speaking with people perceived to have a higher social status can bring someone’s blood pressure up by 50%! Another source of pseudohpertension is that the same size cuff is used for all adults, which can cause significantly false high readings in fat arms. Time of day, room temperature, full bladder, eating, drinking, and smoking within the hour, sitting, standing or lying supine are all facts that influence measurements but are all to often overlooked. Rosch laments the fact that rather than honor the dictum to first do no harm, increasingly doctors are medicating at the first sign of high blood pressure to avoid being accused of malpractice. He suggests that physicians return to the mandate to treat the person rather than the number and rule out all other possible causes of a elevated high blood pressure before prescribing medication in the false name of reducing a persons risk for heart disease.

In the article “The Benefits of High Cholesterol,”Uffe Ranskov presents the provocative argument that people with high cholesterol live the longest. He sites the report that Harlan Krumholz of the Department of Cardiovascular Medicine at Yale made in 1994 that old people with low cholesterol died twice as often from a heart attack as did people with low cholesterol. This is not an exception. There are now a large number of findings that contradict the thesis that high cholesterol is a risk factor for coronary heart disease. In fact, six studies found that total mortality was inversely associated with either total or LDL-cholesterol, or both. This means that it is statistically better to have high than low cholesterol if you want to live to be very old.

Providing another “plus” for high cholesterol, Ranskov sites the study that supports the finding that high cholesterol provides protection against infectious disease. At the end of the study those who had low cholesterol at the start of the study had more often been admitted to the hospital because of an infectious disease. He interpres the results to mean that low cholesterol increases risk of infection rather than infection lower cholesterol, emphasizing the fact that the participants had low cholesterol to start with, before becoming infected. He reinforces the conclusions drawn from this example with the observation that people born with very high cholesterol, so called familial hypercholesterolemia, are protected against infections and the reverse is also true: children with Smith-Lemli-Opitz syndrome are either stillborn or die early because of serious malformations of the CNS. If their diet is supplemented with pure cholesterol or extra eggs, their cholesterol goes up and their bouts of infection become less serious and less frequent. Ranskov goes on to argue that these findings are reinforced by lab experiments done on animals.

Ranskov provides a possible explanation for the seemingly contradictory studies which reveal high cholesterol to be a risk factor for coronary heart disease in young and middle-aged men. He uses the same reasoning that Rosch uses to explain that in such cases, high cholesterol may be a marker of stress rather than a cause of heart disease. The high cholesterol in these young males may reflect the body’s need to produce cholesterol, which is a building block for many stress hormones. In this scenario, any possible protective effect cholesterol may have would be counteracted by the negative influence of a stressful life on the vascular system. But you could not thereby conclude that the high cholesterol is itself a risk factor. Furthermore, Ranskov reasons, if high cholesterol were the most important cause of cardiovascular disease, it should be a risk factor in all populations, in both sexes, at all ages, and for both heart disease and stroke, which is not the case.

In contrast with the weak arguments in support of the claim that high cholesterol is a risk factor of heart disease, he finds his two arguments claiming the opposite, quite compelling: “The first one stems from the statin trials. If high cholesterol were the most important cause of cardiovascular disease, the greatest effect of statin treatment should have been seen in patients with the highest cholesterol, and in patients whose cholesterol was lowered the most. . . . On the other hand, if high cholesterol has a protective function, as suggested, its lowering would counterbalance the beneficial effects of the statins and thus work against a dose-response, which would be more in accord with the results from the various trials.” His second argument is the association between high cholesterol and longevity. He finds it difficult to explain away the fact that during the period of life when most people die (and most of cardiovascular disease) high cholesterol occurs most often in people with the lowest mortality. How could this be possible, he asks, if high cholesterol is in fact a risk factor for heart disease? He concludes that it isn’t, and in the face of the facts, demands that the public and scientific community “wake up!”